PROBATE COURT OF HAMILTON COUNTY, OHIO RALPH WINKLER, JUDGE GUARDIANSHIP OF CASE NO. [ This form may only be used for purposes of a Guardianship Application ] Definition of incompetent [O.R.C. 2111.01 (D): " An Incompetent means any person who is so mentally impaired as a result of a mental or physical illness or disability, or mental retardation, or as a result of chronic substance abuse, that the person is incapable of taking proper care of the person's self or property or fails to provide for the person's family or other persons for whom the person is charged by law to provide , or any person confined to a correctional institution within this state.'' The statement of evaluation does not declare the prospective ward competent or incompetent, but is evidence to be considered by the Court. The fee for completing this evaluation WILL NOT be paid by the Court. Each evaluator should secure payment from the Applicant. 1. 2. This statement of expert evaluation is for the Guardianship Application. (To be completed by a Licensed Physician, or Licensed Clinical Psychologist, and attached to the Application). Statement completed by: Name: Address: Phone Number: who is a: 3. Licensed Physician Licensed Psychologist STATEMENT OF EXPERT EVALUATION Date(s) of evaluation: Place(s) of evaluation: Time spent with ward: Length of time prospective ward has been your patient: Page 1 of 4 H. C. FORM 17.1 - STATEMENT OF EXPERT EVALUATION (GUARDIANSHIP APPLICATION) American LegalNet, Inc. www.FormsWorkFlow.com 09/01/91 CASE NO. 4. Is the prospective ward presently under medication? Yes No If yes, what is the medication, dosage, and purpose. Are there any signs of physical and/or mental impairments caused by the medications themselves? 5. During the examination did you note a disturbance of the prospective ward's: Yes a) Orientation? b) Speech? c) Motor Behavior? d) Thought Process? e) Affect? f) Memory? g) Concentration and Comprehension? h) Judgment? i) Perception of Time and Place? No 6. Please describe any abnormalities identified in question five. (Attach addenda if space is not adequate.) 7. Is the prospective ward mentally impaired? Yes No If yes, what is the cause? 8. Is the prospective ward physically impaired? Yes No If yes, what is the cause? Page 2 of 4 H.C. FORM 17.1 - STATEMENT OF EXPERT EVALUATION American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 9. Did you consult any collateral information in conjunction with your evaluation? No If yes, explain: Yes 10. Please give a summary of background/historical information obtained from the prospective ward and/or collateral source. 11. Could you determine the general level of intelligence and fund of knowledge of the prospective No If yes, explain: ward? Yes 12. Do you believe this prospective ward in his/her present condition, is substantially capable of No If yes, explain: managing his/her finances and property? Yes 13. Do you believe this prospective ward in his/her present condition, is substantially capable of No If yes, explain: caring for his/her activities of daily living or making decisions concerning medical treatments, living arrangements, and diet? Yes 14. Prognosis: In my opinion the application for guardianship Should be granted. Should not be granted Page 3 of 4 H.C FORM 17.1 - STATEMENT OF EXPERT EVALUATION American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. Additional Comments I certify that I have evaluated guardianship. for the purpose of Date of Evaluation Evaluator Page 4 of 4 H.C. FORM 17.1 - STATEMENT OF EXPERT EVALUATION American LegalNet, Inc. www.FormsWorkFlow.com